NEW YORK INSURANCE DEPARTMENT
INDIVIDUAL VARIABLE ANNUITY CONTRACTS
COMPANY: Form No:
Company Contact: Phone Number:
E-Mail Address: Fax Number:
A. All items must be answered. Failure to complete all applicable items will result in this filing
being returned without further review.
B. Check the “YES” box if the item applies without qualification.
C. Check the “N/A” box if the item is not applicable to the policy form.
D. Check the “*” box for the items for which an explanation is necessary. Attach the
explanation(s) referencing the relevant item number(s). Also use this box if you are unsure of
the appropriate box to check.
E. Where required enter the page and paragraph reference of the policy form. The policy form is
identified by form number at the top of page one of the checklist.
F. The signature of the company contact completing this checklist and the date it was completed
must be furnished on the last page.
I. FILING PROCESS
A. TYPE OF FILING (SELECT ONLY ONE)
1. For Prior Approval Section 3201(b)(1) – CL 1997-14
In accordance with CL 1999-8, the caption or “Re” of the submission letter identifies the form number with a
generic product description from Appendix A and a generic form description from Appendix B for each form.
Includes “FILING FOR APPROVAL” or “FILING FOR INFORMATIONAL PURPOSES” in bold print.
For Expedited Approval Section 3201(b)(6) – CL 1998-2, CL 1997-14
(i) In accordance with CL 1999-8, the caption or “Re” of the submission letter identifies the form number
with a generic product description from Appendix A and a generic form description from Appendix B for each
form. Includes “SECTION 3201(b)(6) DEEMER FILING” in bold print.
(ii) A certification signed by an officer of the Company is included with the filing. The certification identifies
all the New York (or Federal) laws and regulations that specifically apply or are unique to the policy forms
(and rates as required) submitted or certifies compliance with all the applicable New York (or Federal) laws
and regulations in the appropriately identified product outline(s).
For Approval with Certification Section 3201(b)(6) – CL 2000-27, CL 1997-14
(i) In accordance with CL 1999-8, the caption or “Re” of the submission letter identifies the form number with
a generic product description from Appendix A and a generic form description from Appendix B for each form.
Include “PRIOR APPROVAL WITH CERTIFICATION” in bold print.
(ii) A certification signed by an officer of the Company and the required Checklist(s) are included with the
filing. The certification follows the format of Exhibit I attached to CL 27-2000 and certifies compliance with
the appropriately identified product outline.
B. SUBMISSION PACKAGE REQUIREMENTS
2. Forms and transmittal letters are submitted in duplicate. YES N/A *
3. Form identification numbers are in the left-hand corner at the bottom of the cover YES N/A *
page of all policy forms being submitted for approval or informational purposes.
4. All blank spaces for the policy forms are completed with hypothetical data. YES N/A *
5. Forms replace previously approved forms and, if appropriate, a highlighted copy YES N/A *
showing the differences or changes made is attached.
6. If a form replaces a recently approved form that has not been issued and uses the YES N/A
same form number, the original approved form is returned to the Department and
the submission letter states that the form has not been issued.
7. A Statement of Self-Support is attached, for each form as required by Section YES N/A *
4228(h) except for application forms and forms accompanied by a statement
signed by the company actuary that they provide supplementary benefits which in
the opinion of the actuary are de minimis.
8. Each Statement of Self-Support has a declaration that the actuary Yes N/A *
signing the Statement is authorized in writing by the company to execute
9. Each Statement of Self-support has a declaration that the actuary signing Yes N/A *
the Statement is qualified to do so under section 4228(h).
10. Each Statement of Self-Support includes an actuarial opinion that the Yes N/A *
subject policy or contract form is self-supporting based on reasonable
assumptions as to interest, mortality, persistency, taxes, agent’s survival
and expenses resulting from the sale of the policy or contract form.
11. Each Statement of Self-Support has a declaration that a demonstration Yes N/A *
of self-support for the subject policy or contract form has been
12. Each Statement of Self-support has a declaration that, for the subject Yes N/A *
policy form, the requirements of Section 4228(h) have been met.
13. A certification is provided, which is signed and dated by an actuary who is a YES N/A *
member in good standing of the American Academy of Actuaries or the Society of
Actuaries, that the fixed account portion of the separate account annuity contract
form(s) is in compliance with the nonforfeiture requirements of the New York
Insurance Law and regulations applicable to individual fixed deferred annuities
and the variable account portion of the separate account annuity contract form(s)
is in compliance with the nonforfeiture requirements of the New York Insurance
Law and regulations applicable to the variable account portions of separate
account deferred annuities.
14. For tax-qualified endorsements, a certification of compliance from the tax counsel YES N/A *
or other evidence of compliance (i.e., IRS approval) with Code requirements has
15. The submission is being made on behalf of the insurer and a letter of authorization YES N/A *
from the insurer is attached.
16. For market-value adjustment annuity contracts, an actuarial opinion and YES N/A *
memorandum (AOM) is provided as required by §3201 (c)(10) and §44.7 of
17. A copy of the final prospectus or draft prospectus is provided. YES N/A *
18. List of material included in the submission (in duplicate).
Type of Form: Contract Rider Endorsement Amendment Application Certificate
Insert Page Disclosure Statement Submission Letter Statement of Variability
Plan of Operation Other (Specify: )
C. TRANSMITTAL LETTER REQUIREMENT
19. States whether the form replaces a previously submitted form. If yes, the letter YES N/A *
states whether the previously submitted form is currently pending review or has
been disposed (approved, filed, disapproved, withdrawn, rejected, etc).
Unless provided below, the letter identifies the form number , control number
, disposal date , if applicable, and describes the changes and reasons
20. States that the application to be used with this form is an approved form. YES N/A *
21. States this contract is sex-distinct. YES N/A *
22. States the contract is on a sex-distinct basis and will “not” be issued in any YES NO *
employer-employee situation subject to the Norris decision and/or Title VII of the
Civil Rights Act of 1964.
23. States the contract is sex-distinct but unisex endorsements or pages for use only YES NO *
in the Title VII or Norris decision and/or Title VII of the Civil Rights Act of 1964 will
24. States the policy is unisex. YES N/A *
25. Describes any innovative and/or unique features and any special market. (See YES N/A *
Circular Letter 27 (2000) for definition of innovative or unique).
26. Describes any guaranteed living benefit (e.g., guaranteed accumulation or income YES N/A *
benefit) provided in the forms. These benefits provide for a guaranteed floor on
certain elective benefits (e.g., cash surrender value) regardless of the performance
of the variable funds.
The submission materials include a discussion of the risk management for the
product (e.g., hedging, reinsurance or exposure limitations). YES N/A *
27. If life contingent payments are commutable or are accelerated upon commutation YES N/A *
of certain period payments, a full description of how the risk of antiselection is
addressed is provided and states that appropriate disclosure will be provided at
time of commutation.
28. States whether the annuity contract provides cash surrender benefits. If cash YES N/A *
surrender benefits are not provided, the letter identifies the applicable exception in
§44.6 of Regulation 127.
29. States whether the annuity contract does not provide a death benefit prior to the YES N/A *
commencement of annuity payments. An explanation for not providing a death
benefit prior to annuity commencement is provided in the submission letter.
30. States the maximum issue age if the contract provides that the maximum YES N/A *
annuitization date or maturity date is the later of the annuitant’s age 90 or the end
of the tenth contract year.
31. Any bracketed material in the policy, which denotes variable material, other than YES N/A *
hypothetical data has been identified and a detailed explanation provided.
32. The policy does not comply with a specific product outline provision and the YES N/A *
submission letter identifies the provision and provides a complete explanation of
the Company’s position on the issue.
33. States whether the form is intended for delivery in New York, outside New York or YES N/A *
34. States whether the form is funded through the insurer’s general account and/or YES N/A *
one or more separate accounts. States whether the plan of operation of the
separate account has been filed with and approved by the Department.
35. States whether a filing has been made with the Securities and Exchange YES N/A *
Commission (“SEC”) and indicates the status of such filing.
II. CONTRACT PROVISIONS
A. GENERAL REQUIREMENTS
Cover Page Page/Paragraph
36. The licensed New York company’s name appears on the front or YES N/A *
back cover. No other insurer or entity other than insurer is
identified on the cover page with greater prominence than the
New York licensed insurer issuing the contract.
37. The full street address of the company’s Home Office appears YES N/A *
on front or back cover.
38. At least one signature of a company officer is provided. YES N/A *
39. A corporate or company logo or trademark or affiliation appears YES N/A *
on the front or back cover and complies with Section 219.4(p) of
40. No unlicensed insurer name appears anywhere on the form. YES N/A *
41. The contract is not labeled in a manner that would have a YES N/A *
tendency to mislead or deceive as to the true identity of the
insurer, or create the impression that someone other than the
insurer would have any responsibility for the financial obligations
under the contract. See §219.4(a), (l) and (p) of Regulation No.
34-A. The contract should be clearly identified as an annuity
contract issued by the insurer.
42. Free Look provision complies with Sections 3219(a)(9) and YES N/A *
4240(a)(13). [Ten-day minimum period.]
The refund must be equal to the consideration paid for the
contract, including any fees or other charges. YES N/A *
For a modified guaranteed annuity, the refund is at least equal
YES N/A *
to the cash surrender value plus all fees and charges deducted
from the gross consideration or imposed under the contract.
For the variable portion of a separate account annuity contract,
the refund is an amount equal to the sum of (a) and (b) where YES N/A *
(a) is the difference between the premiums paid, including any
fees or other charges, and the amounts, if any, allocated to any
separate accounts under the certificate (Loading Charges), and
(b) is the cash value of the contract, or if the contract does not
have a cash value, the reserve for the contract, on the date of
surrender attributable to the amounts so allocated (Current
43. The “date of surrender” in the free look provision means the YES N/A *
date the contract is actually mailed to the company or the date
the contract holder actually delivers the contract to the company
or to an authorized representative of the company.
The contract holder could surrender the contract to either a
sales representative or a corporate officer at one of the regional YES N/A *
The date of such transfer is the date used to determine the cash
YES N/A *
value of the contract.
44. The policy is sold by mail order and a 30 day Free Look is YES N/A *
45. A descriptive name of the contract is included, such as a YES N/A *
“flexible (or single) premium deferred annuity contract” (“FPDA”
or “SPDA”), “modified guaranteed annuity contract” (“MGA”) or
“market-value adjustment annuity” (“MVA annuity” or “equity
indexed annuity” (“EIA").
46. The cover page states whether the contract is participating or YES N/A *
47. The form identification number is in the lower left-hand corner YES N/A *
of the page.
48. A statement on the cover page or specification page that the YES N/A *
contract fails to provide cash surrender benefits at any time
prior to the commencement of annuity payments.
49. A statement on the cover page or specification page that the YES N/A *
contract fails to provide death benefits at least equal to the
actual accumulation amount prior to the commencement of
Death benefit provision describes how death benefits are
affected by the market-value adjustment (i.e., the death benefit YES N/A *
cannot be adjusted downward but can be increased by a
market-value adjustment). See §44.9(d) of Regulation No. 127.
50. For MVA contracts, the cover page contains a prominent YES N/A *
statement that the contract contains a market-value adjustment
formula and that the operation of the formula may result in both
upward and downward adjustments in cash surrender benefits.
51. For MVA contracts, the cover page contains a description of the YES N/A *
points in time when cash surrender benefits are available
without the application of the market-value adjustment formula.
52. A statement identifying the elements of the contract (such as YES N/A *
benefits or premiums) that are on a variable basis. Section
53. A statement that the contract value of the variable sub-accounts YES N/A *
(and any other variable contract elements) is based on the value
of the separate account assets which are not guaranteed as to
fixed dollar amounts and will increase or decrease in value
based upon investment results. Section 4240(a)(11).
54. For variable accounts, a statement which (i) discloses the YES N/A *
smallest annual rate of investment return which would have to
be earned on the assets of the separate account so that the
dollar amount of variable annuity payments will not decrease; or
(ii) sets forth the conditions under which the dollar amount of
variable payments will not decrease. Section 50.6(b) of
Regulation No. 47).
55. For variable accounts, a statement of any explicit charges YES N/A *
against the assets of the separate account. (Section 50.6(b) of
Regulation No. 47).
56. The contract provides for a bonus interest or credit recapture YES N/A *
upon death and there is prominent disclosure that the death
benefit will be reduced by an amount limited to the
unamoritized bonus interest or credit if death occurs within 12
months of the crediting of such bonus.
57. The specifications page is completed with hypothetical data. YES N/A *
58. The current interest rate for the fixed account is specified and YES N/A *
bracketed to denote variable material.
59. The guaranteed maximum expense charges and fees are YES N/A *
specified, including any withdrawal charges and market-value
60. The guaranteed minimum interest rate for the fixed account is YES N/A *
61. The contract charges are specified. YES N/A *
Table of Contents
62. The policy has more than 3000 words or 3 pages and a table of YES N/A *
contents is included.
B. STANDARD PROVISIONS
63. The contract provides for an entire contract provision and the YES N/A *
contract language complies with Sections 3219(a)(3) and 3204.
64. The application is attached to the contract if it is to be part of YES N/A *
the entire contract. [No application is admissible in evidence
unless a true copy was attached to such contract when issued.]
No insertion in or other alteration of any written application can
be made by any person other than the applicant without his YES N/A *
written consent, except that insertions may be made by the
insurer for administrative purposes only in such manner as to
indicate clearly that the insertions are not to be ascribed to the
65. All statements made by or under the authority of, the applicant YES N/A *
for the issuance, reinstatement or renewal of the policy are
deemed to be representations and not warranties. § 3105 and
66. The phrase “In absence of fraud” is not used – Section II(H)(7) YES N/A *
of Circular Letter No. 4 (1963).
67. Nothing is incorporated by reference, unless a copy is endorsed YES N/A *
upon or attached to the contract. §3204.
68. The contract cannot be modified, nor can any rights or YES N/A *
requirements be waived, except in writing signed by a person
specified by the insurer in the contract.
69. The contract requires payments to be made to the insurer and YES N/A *
provides for a 31-day grace period. The contract language
complies with Section 3219(a)(1) and §50.7(a) of Regulation 47.
70. The contract provides for an incontestability provision and the YES N/A *
contract language complies with Section 3219(a)(2).
71. A two-year or less contestable period is provided. The contract YES N/A *
must be in force during the person’s lifetime for such two-year
72. Contests are based only on “material” misrepresentations and YES N/A *
the provision includes this language or is not contrary to Section
73. Exceptions to the incontestable provision are permitted for non- YES N/A *
payment of required premium, violation of conditions relating to
services in the armed forces, total and permanent disability,
accidental death benefits, statements relating to age, sex or
Misstatement of Age or Sex
74. The contract provides for a misstatement of age or sex, YES N/A *
provision and complies with Section 3219(a)(5).
75. The interest rate credited to or charged against underpayments YES N/A *
and overpayments is specified in the contract and cannot
76. The contract provides only for a misstatement of age provision YES N/A *
because it is a unisex contract.
77. The contract is participating and states that the insurer shall YES N/A *
annually ascertain and apportion any divisible surplus. Sections
3219(a)(6) and 4231.
78. For mutual insurers, the contract is nonparticipating and the YES N/A *
company has a special revocable permit to issue
nonparticipating business. [Note that such permit is not needed
for a separate account annuity contract with no fixed account
79. The dividend options made available include cash, reduction in YES N/A *
premium and accumulate at interest. See §4231(b)(6). [Note
cash is not required for a contract qualified for special tax
treatment under IRC §403(b) to the extent that such payment
would prevent such qualification.]
80. The automatic dividend option when none is elected is YES N/A *
and there is language to that effect in the contract.
81. For contracts that require payments to be made to the insurer, YES N/A *
the contract includes a reinstatement provision complying with
§3219(a)(8) for the fixed account portion and §50.7(a)(2) of
Regulation 47 for the separate account portion of the contract.
Reinstatement is permitted, unless the cash surrender value has
been paid, up to three years from the date of default for the
fixed account portion and one year for the separate account
portion. Evidence of insurability may be required, interest on
overdue payments cannot exceed 6% and interest on
indebtedness cannot exceed the applicable loan interest rate(s).
A new incontestability period can begin upon reinstatement,
pursuant to §3210.
82. The contract includes a statement of the basis for determining YES N/A *
the date as of which the amount to cover such overdue
payments and indebtedness shall be applied to produce the
values arising therefrom under the contract or certificate.
Section 50.7(a)(2) of Regulation 47.
83. The contract specifies the cessation of payment options. See YES N/A *
§3219(a)(7). Such options are in accordance with §4223.
84. With respect to the variable accounts, the contract includes a YES N/A *
provision specifying the options available, prior to the annuity
commencement date, in the event of default of a stipulated
premium payment or of surrender of the contract. Section
50.7(a)(3) of Regulation 47.
The options include the right to receive the cash surrender value
or a paid-up annuity to commence at the maturity date provided
in the contract, if the contract is not surrendered for cash.
85. With respect to the variable accounts, the contract provides for YES N/A *
a surrender charge from the accumulated value of the contract
which approximates the unamoritized acquisition expenses in
arriving at the cash surrender value payable. The surrender
charge decreases as the acquisition costs are recovered. In
addition, the contract specifies the method by which, and the
date as of which, the accumulated value of the contract is
determined. Section 50.7(a)(3) of Regulation 47.
86. With respect to the variable accounts, if only the paid up annuity YES N/A *
option is available, the accumulated value of the contract in the
separate account or accounts of the company at the time of
default will, at the option of the contractholder, be transferred to
the general account of the company to provide a fixed dollar
paid–up annuity. The kind and amount of paid-up annuity and
the conditions of its payment are in accordance with the
provisions of the contract and the purchase rates stipulated in
the contract. [The transfer to the general account may be
subject to a deferral.] Section 50.7(a)(3) of Regulation 47.
C. Section 4240 and Regulation No. 47 Provisions
87. The contract provides income, gains and losses, whether or not YES N/A *
realized, from assets allocated to a separate account shall be
credited to or charged against such account without regard to
other income, gains or losses of the insurer. Section 4240(a)(1).
88. The contract identifies the investments that are contractually YES N/A *
permitted for such separate account. Section 4240(a)(2)(A).
Guarantee of Value
89. The liability under any contract is limited to the contractholder’s YES N/A *
interest in assets allocated to the separate account.
90. The contract does not provide any guarantee of the value of the YES N/A *
assets allocated to a separate account, or any interest therein,
or investment results thereof, or income thereon, except as
permitted under §4240(a)(5).
91. Check One. The separate account guarantees satisfy items YES N/A *
(i) , (ii) , or (iii) of §4240(a)(5) of the Insurance
92. The contract specifies the dates on which the assets of the YES N/A *
separate account will be valued. If there is no readily available
market for assets in the separate account, the contract specifies
how such assets would be valued. §4240(a)(7).
93. The contract states that the insurer will maintain in each YES N/A *
separate account assets with a value at least equal to the
amounts accumulated in accordance with the applicable
agreements with respect to such separate account and the
reserves for annuities in the course of payment that vary with
the investment experience of such separate account. See
§4240(a)(8) and §50.3(a)(1) of Regulation No. 47.
94. The contract contains a statement of the essential features of YES N/A *
the procedures used to determine the dollar amount of the
variable elements thereunder. §4240(a)(11)(A).
The contract states in clear terms that such amounts may YES N/A *
decrease or increase according to such procedure. Section
The contract contains on its first page a statement that such YES N/A *
elements thereunder are on a variable basis. §4240(a)(11)(C).
95. The contract does not state that amounts allocated by the YES N/A *
insurer to one or more separate accounts are held in trust for
the contractholder or owned by any person other than the
insurer. Section 4240(a)(12).
96. The contract provides that the portion of the assets in a YES N/A *
separate account not exceeding the reserves and other contract
liabilities with respect to such separate account shall not be
chargeable with liabilities arising out of any other business of
the insurer. See §4240(a)(12) and §50.3(a)(2) of Regulation
Incidental Death Benefit
97. The contract provides for the payment of a death benefit in the YES N/A *
event of death prior to the annuity commencement date in an
amount not to exceed the greater of (i) the accumulated value
of the contract, (ii) the aggregate amount of stipulated
payments or employee contributions, whichever is applicable,
made under the contract prior to the time of death or (iii) the
highest accumulation amount on any given anniversary. The
contract specifies the date on which the death benefit will be
determined and explains the effect of withdrawals on the death
benefit. Section 50.3(a)(8) of Regulation No. 47.
98. The contract provides for the payment of a death benefit in the YES N/A *
event of death prior to the annuity commencement date in an
amount that is not incidental (i.e., it can exceed the greater of
(i) the accumulated value of the contract, (ii) the aggregate
amount of stipulated payments or employee contributions,
whichever is applicable, made under the contract prior to the
time of death or (iii) the highest accumulation amount on any
given anniversary) and the death benefit provision complies with
the provisions of the Insurance Law applicable to life insurance
contracts. Section 50.3(a)(8) of Regulation No. 47
Mortality and Expense Guarantee
99. The contracts contains a statement that neither expenses YES N/A *
actually incurred, other than taxes on the investment return, nor
mortality actually experienced, shall adversely affect the dollar
amount of variable annuity payments after such payments have
commenced. § 50.6(a)(1) of Regulation 47.
Variable Annuity Computation Method
100. The variable annuity contract contains a concise and clear YES N/A *
statement of the method used in computing the dollar amount
of the variable benefit. Section 50.6(c) of Regulation 47.
The method of computing the dollar amount of variable annuity
payments is such that, if the annual rate of investment return of YES N/A *
the separate account were six and one-half percent at all times
from the issue of the certificate, such amounts would not
decrease. Section 50.6(a)(1) of Regulation 47.
The mortality table and assumed interest rate is stated in the
YES N/A *
Deferral of Payment
101. The separate account annuity contract provides, if and to the YES N/A *
extent permitted or required under the Investment Company Act
of 1940, as amended, and any other applicable federal and state
(i) That the company reserves the right, at its option, to defer
the determination and payment of any cash surrender value
for a period of six months after the demand therefor with
the surrender of the contract, or
(ii) That the company reserves the right, at its option, to defer
the determination and payment of any cash surrender value
for a period of nine months in which installments will be
(iii) That the company reserves the right, at its option, to defer
the payment of any cash surrender value in accordance with
the deferment provisions of the federal Investment
Company Act of 1940, as amended. Section 50.7(a)(4).
102. If illustrations of benefits payable under a separate account YES N/A *
annuity contract are incorporated in or attached to such
contract, the illustration does not include projections of past
investment experience into the future or attempted predictions
of future experience. Section 50.8 of Regulation No. 47
103. If illustrations of benefits payable under a separate account YES N/A *
annuity contract are incorporated in or attached to such
contract, the use of hypothetical rates of investment return (not
in excess of 8%) does not conflict with applicable requirements
of the Securities and Exchange Commission and a corresponding
additional illustration is included using a hypothetical rate of
investment return at least at the same interval below the pivotal
rate of investment return.
D. NONFORFEITURE LAW PROVISIONS (FIXED ACCOUNT ONLY)
Minimum Benefits Statement
104. The contract states that any paid-up annuity benefit, cash YES N/A *
surrender benefit, or death benefit provided under the contract
are not less than those required by the state where the contract
was delivered. Section 4223(a)(1)(D).
Guaranteed Benefit Statement
105. The contract describes the guaranteed benefits, including the YES N/A *
minimum paid-up annuity benefit (with statement of mortality
table and interest rate basis for guaranteed purchase rates),
the cash surrender benefit, and the death benefit, with
sufficient detail to determine the amount of such benefits.
106. The contract specifies the times at which such guaranteed YES N/A *
benefits are payable. Section 4223(a)(1)(C).
107. For MVA annuities, the contract provides sufficient information YES N/A *
to determine the amount of guaranteed benefits, including brief
description of the MVA formula, the circumstances in which it is
applied, statement that a detailed description has been filed
with the Superintendent. Section 4223(a)(1)(C).
Alteration of Benefit Explanation
108. The contract includes an explanation of the manner in which YES N/A *
any paid-up annuity benefit, cash surrender benefit or death
benefit are altered by the existence of any additional amounts
credited, any indebtedness to the company or any prior
withdrawals or partial surrenders. Section 4223(a)(1)(D).
Minimum Values Required By The Nonforfeiture Law
109. The minimum values for any paid-up annuity, cash surrender or YES N/A *
death benefit available under the contract are based on the
actual accumulation amount. Section 4223(c)(1).
110. The term “actual accumulation amount” or other similar term is YES N/A *
defined in the contract to include the net considerations,
minus premium taxes and premium charges,
plus additional amounts,
minus administrative charges, prior withdrawals and partial
surrenders, and the amount of any indebtedness including
interest due and accrued
111. Net considerations are equal to gross considerations less YES N/A *
contract charges and collection charges, subject to a minimum
of $0 for any contract year.
Contract charges are fixed dollar charges that do not exceed YES N/A *
(Check Applicable Box)
$75 for single consideration contracts,
$30 in any year for flexible consideration contracts
Lesser in any year of $30 or 10% of the gross annual
considerations for fixed scheduled consideration contracts.
Collection charges do not exceed $1.25 per consideration.
YES N/A *
112. The premium charge in the contract does not exceed: (Check YES N/A *
10% of the net consideration.
7% of the net consideration for contract with a MVA.
113. The administrative charges for the contract do not exceed $30 YES N/A *
Minimum Interest Rate and Additional Amounts
114. Additional amounts, including interest is guaranteed to be YES N/A *
credited at a rate not be less than 3.0% of the sum of the
actual accumulation amount and the amount of indebtedness.
115. Additional amounts are credited in a manner that complies with YES N/A *
§4232(a) of the Insurance Law.
116. Additional amounts credited to the contract are available to the YES N/A *
contract holder upon surrender of the contract for its cash
surrender benefit, subject to withdrawal charges permitted by
Section 4223. See Section 4232(a)(1)
117. The annuity contract does not track two account balances one YES N/A *
of which credits a higher interest rate on amounts that must be
applied to annuitization or held for long periods of time. See
§§3201(c)(1), 4223, and 4232(a)(1). [Two Tier Annuity
118. For a market-value adjustment contract, the guaranteed rate, as YES N/A *
defined in §44.3(h) of Regulation 127, credited to the actual
accumulation amount under a contract is: [Check Applicable
Guaranteed for a specified period of time equal to the
specified time interval;
Constant or conforms to a schedule of rates provided in, or
declared in advance of crediting pursuant to, the contract;
Not based on actual investment experience; and
A high interest rate such that not more than a minimal
increase in the interest rate is likely to be credited not less
frequently than annually.
For MVA contracts, a guaranteed rate applies to premium to be YES N/A *
received for a deposit period not in excess of two years. A new
guarantee rate is declared for premiums to be received during
each succeeding period not to exceed two years. § 44.5(c)(3) of
120. For market-value adjustment contracts, the interest rate YES N/A *
guarantee on any deposit does not exceed ten years in duration.
See §4223(a)(1)(B), §§44.3(t), 44.5(c) and §44.6(c) of Reg. 127.
121. For market-value adjustment contracts, after age 55 the YES N/A *
contractholder can choose a guarantee period that does not
exceed five years. §44.3(t).
Paid-Up Annuity Benefit
122. The present value on commencement date equals or exceeds YES N/A *
the actual accumulation amount, with present value computed
using the mortality table, if any, and interest rate, if any,
specified in the contract for determining any minimum paid-up
annuity benefit guaranteed in the contract. Income payments
cannot be less than the full account value applied to the
guaranteed purchase rates. Section 4223(d).
123. The guaranteed interest rate and annuity mortality table YES N/A *
utilized in the guaranteed purchase rates is specified in the
124. If projection factors are used, the projection scale and the year YES N/A *
to which the mortality rates are projected are specified in the
125. An expense loading is not applied to the guaranteed annuity YES N/A *
purchase rates for all annuity payout options other than the
lump sum option.
126. For contracts without cash surrender benefits, the present YES N/A *
value of any paid-up annuity benefit prior to maturity (i.e., not
later than the anniversary of the contract next following the
annuitants seventieth birthday or the tenth anniversary if later)
are not less than the present value of that portion of the
maturity value of the paid-up annuity benefit arising from
considerations paid prior to the change to a deferred paid-up
annuity, calculated for the period prior to maturity on the basis
of the accumulation interest rate and additional amounts.
127. For contracts without death benefits prior to the YES N/A *
commencement of any annuity payments, present value is
calculated using the interest rate and mortality table specified
in the contract for determining the maturity value of a paid-up
annuity benefit. Section 4223(f).
An explanation for not providing a death benefit prior to YES N/A *
annuity commencement is provided in the submission letter.
128. The contract provides for the payment of a death benefit in the YES N/A *
event of death prior to the annuity commencement date.
129. The death benefit prior to the maturity date is at least equal to YES N/A *
the actual accumulation amount.
130. The contract does not apply a surrender charge, withdrawal YES N/A *
charge or other charge on death benefit payments.
131. The contract does not apply a surrender charge, withdrawal YES N/A *
charge or other charge on death benefit payments except it
does provide for a recapture of the unamoritized bonus interest
or credit if death occurs within 12 months of the crediting of
132. A market-value adjustment is not used to reduce death YES N/A *
benefits. [Note a market-value adjustment can be used to
provide an increased death benefit.]
Cash Surrender Benefit
133. For contracts not providing “guaranteed rates” (an MVA YES N/A *
contract), a cash surrender benefit is provided at least once
each year, unless contract falls under one of the exceptions
noted above (§44.6(a)(1)-(5) of Reg. 127)). See §44.6(d) of
134. For contracts providing “guaranteed rates” and permitting cash YES N/A *
surrenders, an “unadjusted cash surrender benefit” is available
on each “guaranteed benefit date.” See §4223(a)(1)(B) and
§44.6(c) of Reg. 127. [“Unadjusted cash surrender benefit” is
an amount equal to the actual accumulation amount less
withdrawal charge, but not subject to a market-value
135. If the contract is an I.R.C. Section 403(b) annuity, the cash YES N/A *
surrender benefit requirement is met to the extent such
application would still allow qualification for special tax
136. For contracts not providing “guaranteed rates” other than MVA YES N/A *
contracts, the cash surrender benefit is greater than or equal to
the actual accumulation amount, minus the withdrawal charge
percentage times the sum of (i) actual accumulation amount,
and (ii) amount of indebtedness.
137. For market-value adjustment contracts that are not “premium YES N/A *
specific”, the cash surrender benefit is not less than the excess
of (i) the actual accumulation amount, as adjusted by a
market-value adjustment formula, over (ii) the withdrawal
charge percentage times the sum of (I) the actual
accumulation amount, as adjusted by such market-value
adjustment formula and (II) the amount of any indebtedness
under the contract to the company.
138. For market-value adjustment contracts that are “premium YES N/A *
specific”, the cash surrender benefit is not less than the excess
of (i) the actual accumulation amount, as adjusted by a
market-value adjustment formula, over (ii) the aggregate of the
withdrawal charge percentage under the contract times the
sum of (I) the corresponding portion of the actual accumulation
amount, as adjusted by such market-value adjustment formula,
and (II) the corresponding portion of the amount of any
indebtedness under the contract to the company.
139. Cash surrender benefits are determined in a manner established YES N/A *
pursuant to authority granted by board of directors or a
committee thereof (including any formula that takes into
account changes in interest rates of publicly traded obligations
or other investments). Section 4223(e)(1).
140. This is a MVA contract and the contract provides a minimum YES N/A *
period of 30 days during which the certificate holder may apply
for a cash surrender value without adjustment. The unadjusted
cash surrender value need be available only on a single date,
namely on the guaranteed benefit date in which case the 30-day
application period must precede such date.
141. This is a MVA contract and if the contract allows for a different YES N/A *
procedure or a different specified time interval, or a different
index, or a different guaranteed rate for a new guaranteed
benefit period, the new data, to the extent available, must be
fully disclosed to the contractholder and the contractholder shall
have a period of at least 30 days commencing after the date of
such disclosures during which he or she may apply for a cash
surrender value without a market-value adjustment.
142. For partial cash surrenders, the contract states how withdrawals YES N/A *
will be made from the actual accumulation amount attributable
to each premium on (i) a first-in, first-out basis; (ii) a last-in,
first-out basis; or (iii) a pro rata basis. The actual accumulation
amount attributable to each premium is reduced as of that date
by the amount withdrawn from it to provide the cash surrender
143. Cash surrender values are not available under the contract because: [Check applicable box.]
Contracts issued by any life insurance or annuity company organized and operated, without profit to any private
shareholder or individual, exclusively for the purpose of aiding educational or scientific institutions which are also
organized and operated without profit, and which are issued only to or for the benefit of such institutions or
individuals engaged in the service of such institutions;
Contracts issued to fund any benefits under a pension plan within the meaning of the Employee Retirement
Income Security Act of 1974;
Contracts issued to employers to fund deferred compensation arrangements;
Contracts issued to employers to fund lotteries or other programs of states, municipalities, or agencies or
Structured settlements with payment deferred in accordance with a settlement of a lawsuit involving claims
such as liability claims or medical malpractice claims;
Such other contracts as specifically approved by the superintendent upon a demonstration that cash surrender
benefits are not appropriate.
* See §44.6(a)(1) – (5) of Regulation No. 127.
144. A withdrawal charge is not assessed upon annuitization when YES N/A *
an annuity benefit is provided or upon a death benefit, except
as provided in §4223(a)(1)(E) with respect to annuitization.
[For annuity benefits determined by using the guaranteed
annuity purchase rates in the contract, §4223(c)(1) and (d)
require that the actual accumulation amount be applied to such
guaranteed rates. For an annuity benefit determined by using
the SPIA rate, §4223(a)(1)(E) limits the charge to the lesser of
5% or the withdrawal charge percentage for these contracts.]
145. The withdrawal charge is assessed as: [Check applicable box.]
A flat dollar charge;
A fixed percentage of the premium received;
A fixed percentage of the accumulation value;
A variable amount subject to a market-value adjustment formula which may result in charges capped at 10%,
but need not result in credits.
Other. Please specify:
146. For withdrawal charge assessed as a variable amount, the YES N/A *
contract contains a description of any withdrawal charge
formula, including: §44.4(d)
(i) the provisions of the formula, a description of each element
of the formula and identification of source or publication
where any data used in the formula may be found;
(ii) a statement of frequency with which adjustments made in
accordance with the formula will be made;
(iii) a statement of points in time when contract values are
available without application of the formula, and for how
long they are available on an unadjusted basis;
(iv) a description of any waivers of the withdrawal charge;
(v) a description of application to additional premiums under
147. If any withdrawal charge is applicable, the contract includes YES N/A *
(i) a description of the withdrawal charge or withdrawal
(ii) a description of the amounts the withdrawal charge will
be applied against, when, and in what order, (e.g., first
in, first-out basis);
(iii) a description of how withdrawal charge schedule applies
to additional deposits under flexible premium contracts;
(iv) the circumstances under which any waiver of the
withdrawal/surrender charge will be available.
(Note: The withdrawal charge schedule usually appears on the
148. For contracts that do not provide cash surrender benefit YES N/A *
subject to a MVA, the withdrawal charge percentage for fixed
accounts is not greater than 10% less the premium charge
149. For MVA contracts, "withdrawal charge percentage" means a YES N/A *
percentage not greater than seven percent reduced by one
percent for each year the contract has been in force or, if the
contract is premium specific, for each year after the net
consideration associated with such withdrawal charge
percentage was credited to the contract and less the premium
charge percentage, if any, provided in the contract (but not less
than zero). § 4223(e)(4)
150. For MVA contracts, after any period during which interest was YES N/A *
credited to the fixed account at a specified rate and the
company, pursuant to the contract, set a new specified rate and
a new period during which such rate is to be so credited, the
withdrawal charge percentage for such new period shall be a
percentage not in excess of the greater of (A) any remaining
withdrawal charge percentage at the beginning of the new
period and (B) the lesser of (i) five percent and (ii) one percent
times the number of years in such new period, reduced (but not
below zero) by one percent for each year the contract remains
in force during such period. § 4223(e)(4).
151. For MVA contracts, the contract provides for a date, within thirty YES N/A *
days of the last day of such new period, on which the fixed
account may be surrendered for a cash surrender benefit
determined without the use of a market-value adjustment
formula. [Note if the answer is “No” the withdrawal charge
percentage for such new period is zero.] § 4223(e)(4).
152. For MVA contracts, the MVA formula is described in the contract YES N/A *
and provides for upward and downward adjustments. See
§44.9(b) of Reg. 127. The description contains the following:
(Check Applicable Boxes).
The provisions of the formula and a description of each of the elements used in the formula, along with an
identification of the source or publication where the data used in the formula can be found;
If an index of publicly traded obligations is used in the formula, a statement that in the event that this index is no
longer available, a suitable replacement index, subject to approval of the superintendent, would then be utilized;
If the new guarantee rate is used in the formula, a statement of the procedure to determine the rate to be used
in the event that the new guarantee rate cannot be determined from the company's contracts then being offered
(or then in force), and a statement of the procedure to determine the adjustment in the event that the company
no longer issues guaranteed rate contracts;
A statement of the frequency with which market-value adjustments will be calculated, including the dates to be
used in identifying the interest factors;
A statement of the points in time when contract values are available without the application of any market-value
adjustment formula, and for how long they are available on an unadjusted basis;
A statement that a notice will be mailed at least 15 but not more than 45 days prior to the beginning of each of
the 30-day periods referred to in §44.5(b)(3)(iii) and (iv) of Reg. 127Part and containing at least the information
specified therein (if the periods coincide, a combined notice will suffice); and
In case of flexible premium contracts, a statement as to any separate treatment of premiums as to guaranteed
rates, withdrawal charges, specified time intervals and guaranteed benefit dates.
153. The same MVA formula is applied during periods when its YES N/A *
application would result in an increase in cash surrender
benefits as is applied during periods when its application would
result in a decrease in cash surrender benefits.
If not, the company must demonstrate, to the satisfaction of the
superintendent, that equity to terminating and continuing
contractholders and to the company is better served by use of a
different formula in such circumstances.
154. If a contract limits the amount by which cash surrender benefits YES N/A *
may be increased by application of a MVA formula to a specific
percentage of the actual accumulation amount before deduction
of any withdrawal charge, the same percentage limit applies
during periods when the application of the formula results in a
decrease in cash surrender benefits. If not, the company must
demonstrate, to the satisfaction of the superintendent, that
equity to terminating and continuing contractholders and to the
company is better served by using a different percentage limit in
155. The MVA formula takes into account changes in: [Check YES N/A *
Interest rates on publicly traded obligations or other
Interest rates guaranteed in contracts of the same class as
the contract being surrendered.
See §4223(e)(5), §§44.3(l) and 44.5(b) of Reg. 127.
156. The interest rates used in the formula are determined in a YES N/A *
157. For MVA formulas based on the difference between the contract YES N/A *
guaranteed rates and new guarantee rates, the company
increases the new guarantee rate by not more than 0.25%.
158. The MVA formula takes into account the length of time between YES N/A *
the date on which the contract is surrendered and the next date
on which the contract would have provided cash surrender
benefits determined without the use of any market-value
adjustment formula. See §4223(e)(5) and §44.3(l)
159. The MVA formula does not pass any material risk of asset YES N/A *
default or deterioration in asset quality from the company to the
160. The contract reimposes a market-value adjustment after a YES N/A *
guaranteed benefit date based on a new guaranteed benefit
period, subject to disclosure requirement if there is a different
procedure, specified time interval, index, or guaranteed rate.
Betterment of Rates
161. The contract contains a statement that the annuity benefits at YES N/A *
the time of their commencement will not be less than those
that would be provided by the application of “an amount” to
purchase any single consideration immediate annuity contract
offered by the company at the time to the same class of
annuitants. The “amount” applied under the betterment of
rates provision applies to all payout options other than the
lump sum option.
162. For contracts with cash surrender benefits, “the amount” is YES N/A *
defined as the greater of the cash surrender benefit or 95% of
what the cash surrender benefit would be if there were no
163. For contracts without cash surrender benefits, “the amount” is YES N/A *
defined as the present value of the paid-up annuity benefits
using the mortality table, if any, and interest rate, if any,
specified in the contract for determining any guaranteed
minimum paid-up annuity benefits. The amount is at least
equal to the actual accumulation amount.
164. If the insurer does not sell single consideration immediate YES N/A *
annuities, the contract should indicate this fact and the
submission materials describe company’s practice with respect
to current purchase rates (e.g., reasonable in relation to the
market SPIA rates).
Deferral of Payments
165. There is a statement that the company reserves the right to YES N/A *
defer payment of the cash surrender benefit (including loans)
for a period of six months. Section 4223(a)(1)(B).
166. An annual report is provided to contractholders in accordance YES N/A *
with the requirements of §4223 (k) and if applicable §44.8 (b)
of Reg. 127 and §50.9 of Reg. 47.
Involuntary Cashout of Small Annuities
167. The contract permits the company to terminate and pay the YES N/A *
actual accumulation amount if no considerations have been
received for three years, and either the actual accumulation
amount is less than $2,000 or the portion of the paid-up
annuity benefit at maturity on the plan stipulated in the
contract arising from consideration paid prior to such period
would be less than $20 monthly, calculated on the basis of the
mortality table if any, and interest rate, if any, specified in the
168. The separate account annuity contract provides that, at the YES N/A *
time the annuity becomes payable, the insurer may, at its
option, in lieu of commencing annuity payments, cancel the
annuity and pay the accumulated value to the contractholder if
the accumulated value is less than $2,000, or would provide an
income of less than $20 per month. Section 50.3(a)(9) of
Regulation 47. If the contract permits the insurer to refuse to
commence the annuity payments due to minimum size
requirements (e.g., at least $20 per month), the contract does
not provide for a surrender charge if such refusal takes place.
E. Other Provisions
Annuity Settlement Options / Annuitizations
169. The contract specifies the minimum periodic payment amount, if YES N/A *
any, for any monthly, quarterly, semi-annual, annual or other
periodic annuity benefit payment and provides for a lump sum
withdrawal equal to the actual accumulation amount if none of
the annuity benefit payments calculated under the contract for
such periods equals or exceeds the minimum payment amount
for such periods.
170. The automatic/default settlement option is a life annuity with a YES N/A *
minimum five years certain period, unless otherwise required by
the IRC (e.g., qualified joint and survivor annuity).
171. For all accumulation type deferred annuities (rather than just YES N/A *
fixed scheduled premium annuities), the guaranteed interest
rate and annuity mortality table being utilized for the
guaranteed purchase rates are identified in the contract.
172. If commutation of payments after annuitization is permitted, the YES N/A *
interest rate used for commutation is the interest rate that
equated the amount applied at annuitization to the present
value of annuity payments (i.e., no expense load is permitted).
173. The contract provides for unisex annuity purchase rates for YES N/A *
purposes of complying with the Arizona v Norris decision and
Title VII of the Civil Rights Act of 1964.
174. For variable annuity purchase rates, the assumed interest rate YES N/A *
(AIR) and mortality table are stated in the contract. Expense
loadings are not permitted. Projection factors, if any, are
specified (e.g., if the 1983a table with projection scale G is used,
the year to which the mortality rates are projected needs to be
specified). The full account value is applied to guaranteed
Annuity Commencement Date Waiting Period
175. Under the contract, annuity payments are not scheduled to YES N/A *
commence within 12 months of the date of issue and the
contractholder can elect to commence annuity payments as
early as 13 months from the issue date.
176. The contract specifies a maximum annuitization age or maturity YES N/A *
177. Please check applicable box.
The maximum annuitization age is age 90.
The maximum annuitization age is the later of annuitant’s age 90 or the tenth contract year.
The contractholder can elect a later annuity commencement date.
A contractholder receiving distributions complying with the minimum distribution requirements of the Code does not
need to annuitize.
Transfer Between Accounts
178. The contract describes the restrictions and limitations on YES N/A *
transfers between separate accounts or sub-accounts within a
separate account and the general account. Section 3204.
179. For transfers from the general account the contract provides for YES N/A *
a six month deferral or an equity wash to protect against
Owner and Beneficiary Provisions
180. The owner and beneficiary provisions relating to distributions YES N/A *
comply with Section 72(s) of the Internal Revenue Code.
181. Any change in the owner or beneficiary designation is effective YES N/A *
on the date the notice was signed, subject to receipt by the
182. The contract provides for a maximum loan rate of 7.4% if YES N/A *
payable in advance or equivalent effective rate of interest if
otherwise payable (8.0%), or an adjustable maximum rate
183. The adjustable maximum loan rate does not exceed the greater YES N/A *
of the published monthly average for calendar month ending
two months previous or the cash surrender value rate plus 1%.
184. Adjustments are made on regular intervals at least once every YES N/A *
12 months, but not more frequently than once in any three
month period. The rate charged may be increased when the
adjustable maximum loan rate increases by ½% or more and
must be decreased when such rate declines by ½% or more.
185. The contract provides that interest not paid when due will be YES N/A *
added to existing loan if total indebtedness exceeds loan
186. The contract provides that if total indebtedness exceeds loan YES N/A *
value, the contract may be cancelled with 30 days prior notice.
187. The amount of loan is treated as a partial cash surrender YES N/A *
(without imposition of withdrawal charge) and is subtracted
from the actual accumulation amount and transferred to a
separate loan account with loan repayments transferred from
the loan account to the actual accumulation amount.
188. For MVA contracts, if a loan option is to be made available YES N/A *
under the contract, the amount of the loan is treated as a
partial cash surrender (but without imposition of a withdrawal
charge) which is subtracted from the actual accumulation
amount prior to such loan and transferred to a separate loan
account. Any loan repayments result in transfers from the loan
account to the actual accumulation amount under the contract
and are treated as a current premium remittance for purposes
of determining future market-value adjustments.
189. The interest rate credited on loaned amounts cannot fall below YES N/A *
the minimum guaranteed interest rate in the contract.
Waiver of Withdrawal Charge
190. The contract permits waiver of withdrawal charge upon total YES N/A *
and permanent disability (or more favorable provision) in
accordance with Section 3215 of the Insurance Law.
191. The contract permits waiver of withdrawal charge upon YES N/A *
terminal illness, nursing home confinement or the provision of
long term care either at home or in a nursing home. The
contract is not marketed, advertised or sold as long term care
coverage or as an alternative to long term care insurance.
192. The contract permits waiver of withdrawal charge for contracts YES N/A *
providing guaranteed rates for a short specified time interval
such as one year, if the company fails to declare a new rate for
a new specified time interval, at least equal to a specified rate
which rate shall be at least 0.5 percent lower than the initially
193. The contract does not permit a waiver of the withdrawal charge YES N/A *
(or market-value adjustment) upon a credit rating downgrade.
194. The contract waives a fixed contract fee of a minimal amount YES N/A *
for a separate account annuity contract when the account value
including both the fixed and separate accounts exceed a
specified dollar limit on the contract anniversary.
195. The contract and application do not include reference to YES N/A *
telephone transfers. See §§ 5-701 and 15-301 of the New York
General Obligations Law
196. The contract provides for the crediting of additional interest for YES N/A *
each year after a specified time and the following statements
(i) The additional interest is described in the contract and is
not described as a “reward for persistency”;
(ii) The contract indicates whether the additional interest will
be credited if the crediting rate for considerations received
prior to the end of the specified period falls to the
contractual minimum guaranteed interest rate, and the
contract is clear as to whether the contractual minimum
guaranteed interest rate is impacted by the persistency
Interest on Surrenders
197. The contract contains a provision regarding a deferral period on YES N/A *
payment of surrenders and the language complies with Section
3227 referring to a “10 day” period and using the current
interest rate payable on the interest only settlement option. If
there is policy language on this issue, complete page and
Interest on Death Proceeds
198. The contract contains a provision regarding payment of interest YES N/A *
on the deferral of death proceeds and the language is in
compliance with Section 3214. If there is policy language on
this issue, complete page and paragraph reference.
199. The annuity contract is freely assignable unless otherwise YES N/A *
restricted under the contract for tax-qualification purposes, and
the insurer’s procedures on assignments are described in the
Guaranteed Living Benefits
200. The contract clearly describes any guaranteed living benefits, YES N/A *
including guaranteed accumulation or income benefits. The
contract describes how contributions and partial withdrawals
impact the guaranteed benefits. Section 3219(a)(3).
For GMIBs, the contract discloses the income guaranteed and
does not place undue emphasis on the benefit base used to
determine such income. Section 3201(c)(1).
Enhanced Dollar Cost Averaging
201. The contract describes any enhanced interest rate credited on YES N/A *
amounts allocated to a dollar cost averaging option that is in
excess of the gross investment earnings rate (less appropriate
expense and risk charges). The submission materials identify
the maximum enhanced rate (or the maximum enhancement
over the net investment earnings rate). The contract identifies
the deposits to which such rate applies (i.e., lump sum, first
year, etc.) and the dollar cost averaging accounts available
under the contract.
202. At the time of sale, the applicant is provided with appropriate YES N/A *
disclosure as required by Circular Letter No. 33 (1998) including
disclosure of how the excess rate is recovered.
Bonus Interest or Bonus Credits
203. If bonus interest rate or additional amounts will be credited to
the contract, then all of the following statements are true:
(i) The essential terms and conditions relating to the bonus
feature are set forth in the entire contract (as defined in the YES N/A *
(ii) The contract identifies the deposits to which the bonus YES N/A *
interest rate or credit apply (e.g., single payment, initial
payment, first-year premiums, etc.), and the duration for
which bonus interest rate/additional amount will be credited;
YES N/A *
(iii) The contract indicates whether and how the bonus
interest or credit will be recaptured in the event of early
withdrawal or surrender;
YES N/A *
(iv) The bonus interest or credit will not be recaptured upon
YES N/A *
(v) The bonus interest or credit will not be recaptured upon
(vi) The unamoritized bonus interest or credit will be YES N/A *
recaptured from the death benefit if death occurs within 12
months of the crediting of such bonus. The amount
recaptured does not include the interest on the bonus
amount. There is prominent disclosure on the cover page of
the contract that the death benefit will be reduced by any
recapture made in accordance with this provision.
YES N/A *
(vii) If the bonus interest or credit feature will not always be
offered, the contract provisions pertaining thereto are either
bracketed in the main contract form or set forth in a separate
YES N/A *
(viii) The contract clearly describes any adjustments in
the credits, charges or settlement option rates required to
offset the cost of providing the bonus. YES N/A *
(ix) The maximum surrender charge, including any
recapture of the unamoritized bonus credit does not exceed
10 percent -–Section 4223(e)(3) and 4232(a)(1); YES N/A *
(x) Confirm that disclosure language described in Circular
Letters 13 and 21 of 2000 (i.e., any additional or higher fees
and charges attributable to the bonus interest or credit) will
be provided to applicants.
204. Any bonus interest rate or credit on amounts deposited to the YES N/A *
contract in excess of the gross investment earnings rate less
appropriate expense and risk is clearly described in the
contract. Note the bonus interest rate or credit is the amount
guaranteed above the minimum interest rate and any
additional amounts that would otherwise be guaranteed or
credited under the contract.
205. The policy language does not provide for binding mandatory YES N/A *
E. Equity Indexed Annuity Provisions
206. Cash values are available each year. §44.6(d) YES N/A *
207. The contract does not maintain two account values (one YES N/A *
account with a premium charge of 10% accumulated at a
minimum rate of 3.0% and the other account without a
premium charge with no interest rate guarantee.
208. Additional amounts are declared prospectively and credited at YES N/A *
least annually. [This precludes a point to point design
extending over more than one year or high water look back
209. The participation rate is locked in until the surrender charge YES N/A *
210. The index and participation rate are specified in the contract. YES N/A *
211. Any substantive provision or features provided by the terms or YES N/A *
operation of this contract which have not been addressed by
this checklist are set forth in an attachment or identified in the
Print Name: Date:
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